Provider Demographics
NPI:1447492608
Name:GONG, JENNIFER (DC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-1905
Mailing Address - Country:US
Mailing Address - Phone:510-581-5813
Mailing Address - Fax:510-581-7216
Practice Address - Street 1:95 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1905
Practice Address - Country:US
Practice Address - Phone:510-581-5813
Practice Address - Fax:510-581-7216
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0280740111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0280740Medicare PIN